Intermittent malfunction and regurgitation of a mitral prosthetic valve due to entrapment by a residual subvalvular apparatus

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1 | CASE PRESENTATION

A 55- year- old male who had undergone a 29- mm St. Jude Medical mitral prosthetic heart valve (PHV) surgery 6 months earlier was seen in outpatient clinic for a regular follow- up. Cardiac ausculta-tion revealed intermittent loss of closing clicks followed by grade 4/6 pansystolic murmur over the apex and along the left paraster-nal line. Laboratory findings were unremarkable including thera-peutic international normalized ratio and time in therathera-peutic range was 90%. Bedside transthoracic echocardiography indicated a left ventricular ejection fraction within normal limits with an intermit-tent severe mitral regurgitation, moderate tricuspid regurgitation, and moderate pulmonary hypertension (systolic pulmonary artery pressure: 40 mm Hg). Subsequently, two- dimensional (2D) and real time three- dimensional (RT- 3D) transesophageal echocar-diography (TEE) revealed intermittent entrapment of the lateral leaflet by a mobile subvalvular tissue resulting in severe transval-vular mitral regurgitation (Figure 1A,B and Movie S1). There was no paravalvular leakage or prosthetic valve thrombosis. A small mobile echogenic mass, consistent with residual chordae tend-ineae, was observed on the left ventricular side of the lateral leaf-let of the PHV (Figure 1C and Movie S2). Moreover, RT- 3D TEE

indicated paroxysmally impingement of subvalvular tissue be-tween the lateral side of annulus of the PVH and lateral leaflet of the PHV (Movie S3). Hence, lateral leaflet was prevented from closing adequately. It resulted in intermittent transvalvular mitral regurgitation (Figure 1D). This intermittent mitral regurgitation was also proved by continuous- wave Doppler imaging (Figure 2). Since asymptomatic, he was treated medically and doing well for 4 years of follow- up.

Intermittent malfunction is a rare but potentially serious com-plication of PHV replacement.1 _{It may be observed in both mitral}

and aortic valve prosthesis and may lead to either paroxysmal ob-struction or regurgitation,2 _{depending on the valve location and on}

the phase of the cardiac cycle during which the leaflet is entrapped. The most frequently encountered causes of intermittent valve mal-function are pannus formation, prosthetic valve thrombosis, vegeta-tions, remnants of subvalvular apparatus such as chordae tendineae and suture material.3–5 _{Excessive redundancy of the mitral}

chor-dae tendineae preoperatively and/or inadequate shortening of the subvalvular structures during surgery may cause this complication. Intermittent severe regurgitation of PHV due to residual chordae tendineae is very rare clinical entity, and TEE is an indispensable guide in the differential diagnosis.

Received: 10 August 2018 

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ECHO ROUNDS Section Editors - Edmund Kenneth Kerut, MD and Michael R . McMullan, MD

Intermittent malfunction and regurgitation of a mitral

prosthetic valve due to entrapment by a residual subvalvular

apparatus

Ahmet Güner MD

_{| Macit Kalçık MD}

_{| Mahmut Yesin MD}

_{| Mehmet Özkan MD}

1_{Department of Cardiology, Kosuyolu Kartal}

Training and Research Hospital, Istanbul, Turkey

2_{Department of Cardiology, Faculty of}

Medicine, Hitit University, Corum, Turkey

3_{Department of Cardiology, Kars Harakani}

State Hospital, Kars, Turkey

4_{School of Health Sciences, Ardahan}

University, Ardahan, Turkey Correspondence

Ahmet Güner, Department of Cardiology, Kosuyolu Kartal Training & Research Hospital, Kartal, Istanbul, Turkey. Email: ahmetguner488@gmail.com

Intermittent malfunction is a rare but potentially serious complication of prosthetic heart valve (PHV) replacement. It may be observed in both mitral and aortic valve prosthesis and may lead to either paroxysmal obstruction or regurgitation, depending on the valve location and on the phase of the cardiac cycle during which the leaflet is entrapped. The most frequently encountered causes of intermittent valve malfunction are pannus formation, prosthetic valve thrombosis, vegetations, and remnants of subvalvular apparatus such as chordae tendineae and suture material. Intermittent severe regurgitation of PHV due to residual chordae tendineae is very rare clinical entity, and transesophageal echocardiography is an indispensable guide in the differential diagnosis. Here, we represent an interesting case of intermittent regurgitation of a mitral prosthetic valve due to entrapment by a residual subvalvular apparatus.

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ORCID

Ahmet Güner http://orcid.org/0000-0002-1845-1710

Macit Kalçık http://orcid.org/0000-0002-8791-4475

Mahmut Yesin http://orcid.org/0000-0002-2515-1265

REFERENCES

1. Melenovsky V, Al Hiti H, Lupinek P, et al. Intermittent cardiogenic shock in a man with mechanical prosthesis of the aortic valve. Circulation. 2011;124(1):e1–e3.

2. Moorthy N, Ananthakrishna R, Rao DPV, et al. Prosthetic mitral valve thrombosis, malfunction, and paroxysmal mitral regurgitation. Echocardiography. 2018;35(3):388–390.

3. Giroux SK, Labinaz MX, Grisoli D, et al. Intermittent, noncyclic dys-function of a mechanical aortic prosthesis by pannus formation. J Am Soc Echocardiogr. 2010;23(1):107.e1–107.e3.

4. Ozkan M, Astarcioglu MA, Karakoyun S, Balkanay M. Extrinsic mechanism obstructing the opening of a prosthetic mitral valve: an unusual case of suture entrapment. Echocardiography. 2012;29(2):E28–E29.

5. Fadel BM, Alassas K, Dahdouh Z, et al. Intermittent malfunction

of a prosthetic valve- a diagnostic challenge. Echocardiography.

2016;33(6):916–919.

SUPPORTING INFORMATION

Additional supporting information may be found online in the Supporting Information section at the end of the article.

Movie S1. Two- dimensional transesophageal echocardiography showed an intermittent severe transvalvular mitral regurgitation

F I G U R E   1   Two- dimensional transesophageal echocardiography revealed a mild physiological transvalvular mitral regurgitation during

systole (A) and an intermittent failure in the closure of mitral prosthetic leaflet resulting in severe intravalvular mitral regurgitation during the next systole (B). Two- dimensional transesophageal echocardiography demonstrated a small mobile echogenic mass on the left ventricular side of the lateral leaflet of the mitral prosthetic valve, consistent with residual chordae tendineae (C). Real time three- dimensional transesophageal echocardiography indicated paroxysmally impingement of subvalvular tissue between the annulus of the prosthetic heart valve and lateral leaflet of the prosthetic heart valve and prevented adequate closing (D). IAS, interatrial septum; LA, left atrium; LAA, left atrial appendage; LV, left ventricle; MVR, mitral valve replacement

F I G U R E   2   Continuous- wave Doppler imaging showed

intermittent mitral regurgitation during some of systoles (asterisks). LA, left atrium; LV, left ventricle; MVR, mitral valve replacement

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Movie S2. Two- dimensional transesophageal echocardiography demonstrated a mobile echogenic mass on the left ventricular side of the mitral prosthetic valve, consistent with residual chordae tendineae

Movie S3. Real time three- dimensional transesophageal

echocardi-ography left atrial view showed the residual chordae tendineae on the left ventricular side of the mitral prosthetic valve (arrow)

How to cite this article: Güner A, Kalçık M, Yesin M,

Özkan M. Intermittent malfunction and regurgitation of a mitral prosthetic valve due to entrapment by a residual subvalvular apparatus. Echocardiography. 2018;35:2092– 2094. https://doi.org/10.1111/echo.14188